GASi World

Short-Term Group Analytic Psychotherapy (STGAP)

First posted 4/1/2017

Introduction: The term refers to a time-limited form of Group-Analytic Psychotherapy or Group Analysis (see these terms). Norwegian guidelines for Long- and Short-Term Group-Analytic Psychotherapy were developed to be used in a research project studying different aspects of Group Analytic Psychotherapy (GAP), including the significance of treatment length (Lorentzen, 2004). The guidelines were later translated to English with assistance from members of a task group representing IGA, London and GAS-International, and published by Routledge (Lorentzen, 2014).

Definition: Short-Term Group Analytic Psychotherapy (STGAP) is a clinical approach that aims to relieve mental suffering, work towards resolving internal conflicts, and/or change dysfunctional behavior. Patients suited for STGAP usually have more circumscribed problems and often settle for a more limited change during the course of the therapy. It takes place in a closed group, i.e. all group members start and end therapy at the same time. The group has 7-8 patients and 1-2 conductors (therapists) and consists of 20, 90 minutes weekly sessions.

Basic ideas that STGAP shares with GAP

The therapy is a form of group psychotherapy of the individual, by the group, of the group, including its conductor, B. A person is primarily a social being, bringing her/his socio-biological heritage to the group (foundation matrix), C. The therapist (called conductor) expects that the group members take more initiative and responsibility for the group process. However, since the members naturally will use the group for their own interest, the conductor alone puts the group’s interest first and foremost, and is in the service of the group. D. All communications in the group are transpersonal and affect each member on a conscious and unconscious level. They contribute to the collective group history, they build the group matrix in concert with the foundation matrices and constitute psychological processes that relate to each other in manifold ways and on a variety of different levels. E. The therapeutic process consists of an increasing deepening of the communications in the group, translating (interpreting) latent aspects of the relational/emotional interactions, establishing more and more specific meaning by joint exploration. The group members are instrumental in this process because all contributions that follow upon each other are in part idiosyncratic associations and in part relevant reactions and responses to what has been going on before. This is a way of group communication that Foulkes called a free-floating (or free group) discussion. F. In order to fulfill her/his complicated tasks of both serving the group and treating individual patients, the therapist should maintain a bifocal orientation, keeping an eye on both the individuals and the group-as-a-whole.

Modifications in Short-Term Group Analytic Psychotherapy

Most of these are due to the reduced time in treatment and the fact that STGAP takes place in a closed group.

Pre-therapy evaluation and information

Clinical experience and research evidence calls for a thorough evaluation of the patient’s problems (pathology) and resources. Conductor/patient should be able to negotiate a focus for therapy (an internal conflict, a set of symptoms, or preferably a dysfunctional interpersonal pattern, which constitutes or is related to the patient’s main problems). The patients should be interested in working with these problems (motivated for change). The therapist should give relevant information about the therapy and both parties should share mutual expectations. The evaluation/preparation usually requires several pre-therapy individual sessions.

Modifications of therapist role and conceptualization of the group process

The therapist should be more active and adapt to the group member’s own activity. She/he has an important function in trying to speed up the development of group relationships (cohesion) and to model interpersonal skills. To promote early interactions, group members, in the first session, take turns to introduce themselves, presenting the main issues they previously have discussed with the therapist, and that they want to work with in the group. The therapist asks questions to clarify certain issues, ties themes from different members together, differentiates the group from other social situations (build boundary), and carefully facilitates interactions. Important thumb rules throughout the therapy are to do more focused work and to use boundary issues for understanding and demonstrating latent meaning of behavior.

In STGAP the group process is understood in four phases: engagement, differentiation, interpersonal work, and termination (MacKenzie, 1997). All phases have specific challenges for the members, for the group-as-a-whole, and for the therapist, which have to be solved for the group to move on. The therapist uses the phases as a back-drop that may assist in understanding what is going on in the group, but also to suggest formulations for interventions. Most part of the interpersonal work should take place in the here-and-now, and the therapist should actively remind the group about the impending termination.

Indications for STGAP: Patients with circumscribed problems, agreement about focus (interpersonal problems), and motivation to work with the problems. On the resource side, patients should have a moderate to high level of structural integration (quality of object relations), which encompass a predominant use of more mature defense mechanisms, and a moderate degree of psychological mindedness (mentalizing function). It should be underlined that mild to moderate personality pathology and certain types of acting out can be successfully treated in time-limited groups. These aspects of personality and dysfunctional behavior should have been discussed during evaluation and acknowledged by the patient, identified as a potential threat to the therapy, and maybe even been made the focus (main problem) to be worked with in the group.

There is scarcely any research evidence for treating patients with psychotic disorders, severe personality disorders, addictions, and organically based disorders in time-limited groups.

Research evidence:

Group analysis has not developed a tradition for systematic empirical research and practice rests to a large extent on clinical experience. Modified group analytic psychotherapy of varied durations is probably commonly used in different contexts (hospitals, prison) or with hard-to-treat patients, but systematic documentation from such practices are scarce. A systematic review of group analysis and analytic/dynamic group psychotherapy, carried out by Centre for Psychological Services Research, School of Health and Related research, University of Sheffield, UK, also, in their conclusion, commented on the lack of research and the poor quality of some of the existing studies (Blackmore, Tantam, Parry and Chambers, 2011). However, they acknowledge that the reviewed studies consistently reported that group psychotherapy is an effective approach, across diverse conditions and settings. Concerning the time perspective of therapy, eight of the 12 controlled studies in the review were on short-term therapy (< 3 months) and demonstrated that psychodynamic group therapy was effective for complicated grief, binge-eating disorder, and occupational stress. A sample with mixed diagnoses also improved during 8 sessions, but the effects were not sustained a few months later. Two observational studies of mixed diagnoses or schizophrenia gave few effects, while patients with childhood sexual abuse improved pre-post, but the effects were not sustained at 8 months follow-up.

The STGAP principles and characteristics presented here, are based on guidelines (Lorentzen, 2014), which again encompass evidence from time-limited dynamic psychotherapy and the author’s experiences from training in psychoanalysis, short-term individual psychotherapy, and group analysis, combined with an extensive clinical and research experience. Results from a RCT comparing the outcome of short- (STGAP; 6 months) and long-term group analytic (GAP; 2 years) therapy with a mixed diagnostic sample of outpatients are included as evidence for the effectiveness of STGAP: The average patient has a similar outcome at 3 years after baseline, in both therapies. However, patients changed faster in the short-term format (Lorentzen, Ruud, Fjeldstad and Høglend, 2013). This effect is sustained from 4-7 years in STGAP, while patients continue to change in GAP (Lorentzen, Fjeldstad, Ruud and Høglend, 2015). Although patients with more personality pathology changes most in GAP, they also change some during STGAP, and stay improved for several years (Lorentzen, Ruud, Fjeldstad and Høglend, 2015). Patients without personality disorder seem to change little after 6 months (Fjeldstad, Høglend and Lorentzen, 2016).

References:

Blackmore, C., Tantam, D., Parry, G. and Chambers, E. (2012) ‘Report on Systematic Review of the efficacy and clinical effectiveness of Group Analysis and Analytic/Dynamic Group Psychotherapy’, Group Analysis 45: 46-69.

Fjeldstad, A., Høglend, P. and Lorentzen, S. (2016) ‘Presence of Personality Disorder Moderates the Long-Term Effects of Short-Term and Long-Term Psychodynamic Group Therapy: A 7-Year Follow-up of a Randomized Clinical Trial’, Group Dynamics: Theory, Research and Practice. http://dx.doi.org/10.1037/gdn0000055